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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002740
Report Date: 10/27/2021
Date Signed: 10/27/2021 08:55:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SUNRISE HOMESFACILITY NUMBER:
397002740
ADMINISTRATOR:ELIZABETH ABESAFACILITY TYPE:
740
ADDRESS:8100 S. BRIGHT ROADTELEPHONE:
(209) 234-2550
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:15CENSUS: 10DATE:
10/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Elizabeth AbesaTIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced on 10/27/2021 at 8 am to conduct an unannounced case management visit following an incident report submitted to the department. LPA met with Administrator and stated the purpose of the visit. Current census is 10.

During the visit LPA conducted interviews and reviewed records. LPA reviewed record of one incident where Resident one (R1) was observed to show behaviors off baseline of attempting to burn clothes. R1's responsible party and physician was notified. R1 admitted to hospital for evaluation and symptoms resolved after medication administered per physician's orders. R1 observed regularly was revaluated after incident and will follow increased appointments. Administrator stated the facility will continue to provide increased monitoring and coordination for psychiatric appointments to observe R1 for changes in conditions. LPA observed physician's report last updated in 12/2015. LPA provided technical assistance to update physician's assessment and document updated care plan to ensure R1's increased monitoring is documented and available for records review.

LPA conducted a case management inspection to ensure proactive measures were put in place to prevent further incidents. If there is another reoccurrence of the same nature the department will require resident be reassessed by their physician to determine if the current placement continues to be appropriate.



Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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